Form Fis 0850 - Financial Statement For Third Party Administrators (Tpas)
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3FIS 0850 (1/04) Office of Financial & Insurance Services
For the fiscal year
Financial Statement for Third Party Administrators (TPAs)
Beginning
All TPAs file a financial statement at the time of their initial request for Certificate of Authority in Michigan, and annually
thereafter with a $25 statement filing fee. Use financial data for the TPA, not the TPA's parent company.
Ending
You may submit a completed independent audit in lieu of pages 2 and 3 of this form. The audit must be accompanied by
Statement and fee are due annually by
an opinion prepared by a CPA and must include all of the items listed on pages 2 and 3 of this form.
March 1st for all TPAs with a Michigan
Certificate of Authority.
Always complete and attach this page to every TPA Financial Statement or Audit you file.
Name of TPA
TPA Tax ID number (FEIN)
Address of TPA principal office (include street address)
TPA Mailing address
Same as principal office address
Number, street and floor or suite number
Number, street and floor or suite number
PO Box
City
State
Zip
City
State
Zip
Contact person name and title (for inquiries regarding this Financial Statement)
Contact person EMail address
Contact person phone (with area code)
Please review the information you presented in your original TPA application for a certificate of authority in Michigan.
Report any significant changes to the Office of Financial and Insurance Service within 30 days of the change.
Verification
Certification of Notary Public
I swear under penalties of perjury that the information above and attached is true,
State of _________________ County of ____________________
accurate and complete.
On this __________ day of ___________, 20___, before me, the
Signature
Date signed
undersigned notary, personally appeared
___________________________________________________,
personally known to me, or proved to me through government-issued
documentary evidence in the form of
Signer's name and title (typed or printed)
_____________________________________ to be the person(s)
who signed the preceding document in my presence and who swore or
affirmed to me that the signature is voluntary and the document truthful.
PA 218 of 1956 as amended requires submission and verification by Third Party Administrators who have, or
are requesting a Michigan Certificate of Authority. Failure to properly complete and file or amend this form may
result in denial or revocation of Certificate of Authority or other compliance action.
Official seal and signature of notary
If this is an ANNUAL financial statement filing, a filing fee of $25 is due.
Please attach a check for $25 payable in US Dollars to "State of Michigan"
If this is your INITIAL financial statement filing, please DO NOT submit this fee.
Official use only
Office of Financial and Insurance Services
Invoice number
Date paid
Processor
611 W. Ottawa St.
Please mail your
completed filing to:
PO Box 30220
Lansing, MI 48909-7720
Validation Code 87-10-70
Michigan Department of Labor & Economic Growth
Visit OFIS online at:
Phone OFIS toll-free at: 1-877-999-6442
The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
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